Joel Landau

🙏 Cigna ER Analysis Updated - Thank you LinkedIn Network! 💡Split Analysis between Professional vs Institutional Rates 👉Prof = Up to 58 X Medicare, Inst = Up to 95 X Medicare

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If you click on the link you will see a report called Expense Distribution. I know this report more than you can imagine. It's based on paid claims. It shows that for this plan half the members were essentially self-insured as individuals. If I was the CEO of this company, you can bet I would make sure the rates my employees were paying for their own care were reasonable. If not, I'd be personally liable. #deerhold #ContractRateExplorer #MRFInsights

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Will US Pharma Predatory Pricing Bankrupt Medicare? GLP-1's VS the entire senior population of the USA Medicare total spending hit $5.7 billion in 2022 for GLP-1s, up from $57 million in 2018 This could ONLY HAPPEN in the USA What do they pay in Canada? (or any other first world country?) From the article: "Today's report makes it crystal clear: The outrageously high price of Wegovy and other weight loss drugs have the potential to bankrupt Medicare and our entire healthcare system,"  Mr. Sanders said.  "The unjustifiably high prices of these weight loss drugs could also cause a massive spike in prescription drug spending that could lead to an historic increase in premiums for Medicare and everyone who has health insurance." https://lnkd.in/gY5PDq_A

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I have written before with conviction and faith about NADAC pricing for drugs reimbursed to pharmacies. Why retail and independent pharmacies cling to faulty PBM contracts with the usual suspect of reimbursement benchmark of AWP. AWP is archaic and it certainly does not favor a pharmacy. As a Founder & CEO of a Hospice PBM and my past business experience of owning a pharmacy for over 20 years - pharmacies especially the independents have a soft place in my heart. That is why I believe treating the independent pharmacy as your partner we can all share in the success of the paying client or the customer as a happy customer. Margins are tight and the squeeze is tightening further. CMS gave all hospice providers a 2.5% increase. In the hospice PBM world think of it this way the average national cost per patient per day is around $12.50. Now reflect on all other nursing costs, visit costs, caregiver costs, aids etc and then you realize AWP is hurting the paying client not helping. Cap Rx keep on, keeping on!

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The Bismarck private healthcare model enables access for all to private manufactured and private insured medical care with more competing hospitals and insurers per capita than in America and with better outcomes than in America simply by making health insurers capitated utilities instead of luxury high market cap conglomerates. Read about Bismarck here. https://lnkd.in/evX8nur Statutory health insurance in Germany: a health system shaped by 135 years of solidarity, self-governance, and competition https://lnkd.in/ecUwsHWP

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Some good insight here. One best practice everyone should focus on is connecting the chronic conditions found to best practices for quality of care in managing them.

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Let's keep hospice focused first and foremost on the PATIENT. After all, we only get one chance to do it right... "There are six primary trends that are influencing consolidation and professional practices: regulatory complexity. technology and integration, private equity ownership. demographics, economies of scale and consumer expectations,” Henderson said. “So many of these things that we see that are influencing health care consolidation need to be pointing toward the patient." #patientsfirst #hospicecare #youonlygetoneshot https://lnkd.in/gbbgV-YF

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The California Office of Health Care Affordability has recently approved a requirement that all healthcare providers report their annual operating expenses. If those expenses increase more than 3.5% (eventually lowering to 3%) in a year, that provider will be fined, ironically increasing their expenses. The state claims this regulation is aimed at protecting consumers from high healthcare costs. This is the same State of California that recently raised all healthcare workers' minimum wage to $25 per hour (up from $15.50).  For our health system, that results in a $30 million annual cost increase and a 7.5% increase in our salary costs. This is also the same state that passed an unfunded mandate that requires our system to spend about $1 billion to replace a hospital building that they feel is at risk from damage in an earthquake. And it’s also the same state that increased the cap on medical malpractice lawsuits…and has authorized utility companies to raise their rates 15% per year.  So, with all of these unfunded requirements and policies that dramatically increase providers' costs beyond their control, how exactly does the state suggest that we limit our expense growth to 3% per year?  Healthcare cost inflation has already been running at more than 5% before any of these new requirements took effect. Perhaps if California wants to get serious about reducing the cost of healthcare they might look at the managed care plans. The most recent data I could find from the California Health Care Foundation indicates that California managed care companies made $222 billion in 2020. What direct value did these companies provide to the health of our communities? Meanwhile, hospitals and physicians are providing direct patient care and struggling to survive- especially systems like Kaweah Health that serve a high percentage of Medi-Cal (Medicaid) and Medicare patients.  On a side note, the governor did sign a new managed care organization tax into law this year, which was promised to increase Medi-Cal reimbursements to providers, but all signs suggest that he now intends to use those proceeds (nearly $7 billion) to fill holes in his budget's general fund deficit and will not be providing Medi-Cal rate increases. I would humbly suggest that if the state is genuinely concerned about its residents' cost of living, they might look at the state income tax (highest in the country), its gas prices (highest in the country), the essentially unaffordable housing costs, or countless other factors that will have a larger impact on individuals' pockets than beating up healthcare providers with laws that don't make any sense. #hospitals #california #healthcare

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The Critical Need for Accurate Remote Patient Monitoring in Medicare With the rise of remote patient monitoring (RPM), ensuring proper oversight is essential for patient safety and care quality. Recent scrutiny from the Office of Inspector General (OIG) highlights gaps in Medicare's oversight, emphasizing the importance of getting RPM right. Accurate and reliable RPM can improve patient outcomes by providing real-time health data and enabling timely interventions. However, without stringent oversight, the potential for errors and misuse could undermine its benefits, especially for vulnerable populations. For healthcare providers, regulators, and innovators, now is the time to prioritize accountability and precision in RPM systems. Patients' health depends on it. #PatientCare #RemoteMonitoring #HealthcareInnovation #Medicare #HealthTech

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The Hidden Consolidation in Healthcare: What Providers Need to Know Did you know that major health insurers are quietly becoming major healthcare providers? 🏥 United Healthcare (via Optum) owns ~10% of U.S. physician providers 🔵 Anthem/BCBS likely owns a similar or greater percentage 💼 Aetna and Cigna are following suit Why does this matter? 1. Decreasing reimbursements: Payer-owned providers essentially pay themselves, making reimbursements an accounting trick. 2. Steering patients: Insurers will likely direct patients to their own providers. 3. Competitive disadvantage: Independent providers face an uphill battle. Real-world example: Notice struggling mental health reimbursements in TX, IL, NM, OK, MT from BCBS? It's no coincidence HCSC (BCBS holding company) invested in Headway. (Links in comments). This is why negotiations are no longer just administrative. It requires deep industry knowledge, M&A experience, and accounting expertise. At Opilio, we've helped clients achieve an average 16% increase in reimbursements. Our unique blend of payer, healthcare M&A, accounting, and revenue cycle management experience sets us apart. Don't let your practice get left behind. It's time to negotiate transparent, objective, and sustainable reimbursements. Protect your practice's future. Let's talk. #HealthcareStrategy #ProviderAdvocacy #ReimbursementNegotiation

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My latest article in Crain Currency delves into the intersection of HNWI's and Health, Wealth, and Overspending on Healthcare. Exploring the concept that "Healthcare is Wealthcare." #HNWI #Healthcare #Wealthcare

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What does health insurance do? The conversation in the attached screenshot sums it up. We have a distorted market in healthcare. For drugs, there is a middleman called PBM between the insurance and the drug companies. The PBM negotiates a higher rate than the cash price - usually 2x or 3x and then receives an under the table rebate from the drug company. It passes of portion of this rebate to the insurer. The end effect is that the bottom price for the consumer is increased. The consumer believes that their insurance saved them a lot of money. #healthcare

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By: Don Self, CMCS, CPC, CASA          Karlene Dittrich, CBCS, CPC, CPMA, CECCS         Chris Chapman, CPC, CPMA     Is Your Practice Or Organization Receiving Negative Financially Impacted UHC Responses? , Please  Read Below and Complete Our Short Survey.  The aggregated survey results will be posted on Don's list serve   After listening to the Senate Finance Committee hearing May 1st with testimony by Andrew Witty, CEO of UHG, it was clear that the US Senate & House members DO NOT HAVE A FACTUAL UNDERSTANDING OF UNDISCLOSED ACTS BEING TAKEN BY UHC.   We believe some statements by Mr. Witty to be misleading in nature, especially when considering facts posing financial risk to healthcare organizations.  Mr. Witty said that UHG is doing everything to help physicians, clinics and hospitals and that at no point has UHG or its companies  tried to take advantage of its own cyber attack. He stated that claims are processing implying claims payments are being made but failed to disclose  the relevant denial tactics being applied to the processed claims.  However, we have already observed since the Feb 21 attack, an increase in clients reaching out to us due to "post-payment" medical record requests, refund demands & recoupments/offsets and extrapolation attempts from UHC being received by clinics across the USA, that appear to FAIL to meet compliance with applicable state and federal laws. This is HUGE & the committee seems unaware of such detrimental undisclosed financial acts being intentionally exercised by UHC.  As advocates, we would like to show Congressional members proof in numbers of what is really happening, however WE NEED YOUR HELP to report the magnitude of UHC's attempts to recoup or "claw-back" money (patient benefits) previously paid on claims.   If you received one or more Refund Demand/Overpayment notices, recoupment(s) or offset(s), extrapolation notifications  or "post payment" medical record requests, please help us inform the Senate Finance Committee what is really going on by filling out the short survey in the link below.  The data needs to be close estimates. We are not asking for any PHI, or copies of documents or evidence, yet  Your responses will be confidential and only shared with  us & the committee (without the name of your organization).  Also, please provide us contact information & impacted locations in case we need to reach back out to you.  Please at least include the city/states so that we can provide the Senate Committee with geographically accurate reports.  If the Senate Committee wants to see actual examples or evidence, we will reach out to you with info you can get in touch with them directly.   Short and Optional Survey  https://lnkd.in/gGKhKr2A     The May 1st  recording is available at: https://lnkd.in/g_CaZ-vy    

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Does your practice embrace ancillary revenue streams? With the cost of everything rising and surgeon reimbursements decreasing, shown by CMS’s proposed 2.8% physician payment cut for 2025 (I’ll link the article in the comments) - leaders of private practices are prioritising new, compliant revenue opportunities. Ancillary revenue streams aren’t optional - they’re essential. Calling them “ancillary” is perhaps misleading, as sustainable, compliant revenue has become critical to survival. At WRS Group, it took us 12 years to develop an elegant, compliant solution for dispensing rented cold compression therapy. Here’s what we focus on: • Patient efficacy: proven outcomes that improve recovery. • Regulatory compliance: designed to meet rigorous federal and state guidelines  • Meaningful revenue: delivered in-network with payors to ensure sustainability. Michael Bercik MD, an orthopedic surgeon specializing in shoulder and elbow care, says: "It's just win, win, win, win. I've spoken to colleagues about this.... like, "Hey you gotta do this."" The challenges facing private practices are real, but solutions exist. By prioritising innovative revenue streams, practices can remain financially viable while continuing to provide exceptional care. Please reach out to learn more! #Orthopedics #AncillaryRevenue #WRS

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#fraud, #healthcare, #The Wall Street Journal WHAT A SHAME - Insurers Pocketed $50 Billion From Medicare for Diseases No Doctor Treated https://lnkd.in/dRKitYtW Private insurers involved in the government’s Medicare Advantage program made hundreds of thousands of questionable diagnoses that triggered extra taxpayer-funded payments from 2018 to 2021, including outright wrong ones like Lee’s, a Wall Street Journal analysis of billions of Medicare records found. The questionable diagnoses included some for potentially deadly illnesses, such as AIDS, for which patients received no subsequent care, and for conditions people couldn’t possibly have, the analysis showed. Often, neither the patients nor their doctors had any idea. Medicare Advantage, the $450-billion-a-year system in which private insurers oversee Medicare benefits, grew out of the idea that the private sector could provide healthcare more economically. It has swelled over the last two decades to cover more than half of the 67 million seniors and disabled people on Medicare. Instead of saving taxpayers money, Medicare Advantage has added tens of billions of dollars in costs, researchers and some government officials have said. One reason is that insurers can add diagnoses to ones that patients’ own doctors submit. Medicare gave insurers that option so they could catch conditions that doctors neglected to record. The Journal’s analysis, however, found many diagnoses were added for which patients received no treatment, or that contradicted their doctors’ views. ...Insurer-driven diagnoses by UnitedHealth for diseases that no doctor treated generated $8.7 billion in 2021 payments to the company, the Journal’s analysis showed. UnitedHealth’s net income that year was about $17 billion. ...Humana disputed the Journal’s calculation that the company had received $2.2 billion in 2021 payments from insurer-driven diagnoses, saying that total didn’t reflect chart reviews that lowered payments by removing diagnoses.

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Value = Quality/Cost So to truly improve value, you can improve quality, reduce cost, or both. Many MA plans did neither. They just increased revenue by optimizing risk adjustment revenue, which is how you increase price in the risk adjustment model. Same quality at a higher price cannot lead to value. Medicare Advantage plans are licking their wounds, discontinuing plans, paying penalties for over-billing and exiting markets. Why? In large part because they were enamored with increased revenue from maximizing risk adjustment, but didn't have the foresight and discipline to couple the diagnosis capture with meaningful care improvement. The solution: If you document a diagnosis, do something clinically meaningful to improve quality of care in a way that prevents downstream costs due to hospitalization or unnecessary treatment. This is not the same as UM, which is based on denials and prior authorization, which are main tools used by most health plans. You just diagnosed COPD? First off, make sure your diagnosis is solid. Did you use a symptom assessment tool followed by spirometry? Once ACCURATELY diagnosed, refer to virtual pulmonary rehab and a high value care management program. Same for CHF, DM, severe asthma, ckd3+, afib, etc... Forget MEAT, which has been the risk adjustment documentation mantra (manage, evaluate, assess, treat). Instead, try DDD: Diagnose, then Do something Dummy...

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